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Progress Notes are the part of a medical record where healthcare professionals record details to document a patient's clinical status or achievements during the course of a hospitalization or over the course of outpatient care. [1] Reassessment data may be recorded in the Progress Notes, Master Treatment Plan (MTP) and/or MTP review. Progress ...
The four components of a SOAP note are Subjective, Objective, Assessment, and Plan. [1] [2] [8] The length and focus of each component of a SOAP note vary depending on the specialty; for instance, a surgical SOAP note is likely to be much briefer than a medical SOAP note, and will focus on issues that relate to post-surgical status.
Health care professionals use them to record a patient's baseline status and may write additional on-service notes, progress notes , preoperative notes, operative notes, postoperative notes, procedure notes, delivery notes, postpartum notes, and discharge notes. These notes constitute a large part of the medical record.
This framework became widely used in both medical and mental health settings, offering a structured yet flexible approach to documentation that supported clinical reasoning and treatment planning. [65] [66] Progress notes also gained prominence in mental health, tracking clients’ clinical status and treatment progress across sessions.
Mental health encompasses emotional, psychological, and social well-being, influencing cognition, perception, and behavior.According to the World Health Organization (WHO), it is a "state of well-being in which the individual realizes his or her abilities, can cope with the normal stresses of life, can work productively and fruitfully, and can contribute to his or her community". [1]
Despite this progress, the system is still seen as inadequate in many ways by major evaluations of the mental health system. In 2002, the President's New Freedom Commission on Mental Health evaluated the current system of mental health in the United States. The commission concluded that there were "unmet needs and that many barriers impede care ...